Conditions Flashcards
What is the definition of a collapse?
A collapse is a sudden transient loss of consciousness leading to a fall.
What are the two main types of collapse?
Syncope & Non-syncopal attacks
What is syncope? What is the pathophysiology?
Syncope is sudden, transient & self limiting loss of consciousness caused by transient global cerebral hypoperfusion
What are the main causes of syncope? (4)
Acute illnesses
infection, dehydration, MI, PE, Haemorrhage, Aortic dissection
Neurally mediated reflexes
- Vasovagal syncope (faint)- vagal stimulation secondary to a stimulus ( e.g. pain, fright, emotion) —> reflex bradycardia & vasodilation —> hypotension —> syncope, usually an autonomic prodrome ( pale, clammy, light-headed), followed by nausea/abdo pain —> syncope
-Situational syncope
reflex mediated via Vasovagal system, but to specific stimuli
E.g. cough/sneeze, defecation, post exercise, long periods of strain
-Carotid sinus hypersensitivity
- increased pressure ( e.g. neck turning) on hypersensitive carotid body ( baroreceptor)—> bradycardia & vasodilation —>hypotension —> syncope ( common in elderly)
Orthostatic
-
Orthostatic (Postural) Hypotension
Impaired autonomic reflexes —> pooling of blood in veins of lower limbs —> cerebral hypoperfusion & syncope
Can be caused by primary autonomic failure syndromes ( within nervous system) or secondary (caused by another disease)
Secondary - diabetes, Parkinson’s
-Medication/ Alcohol
-Volume depletion
**Cardiac related **
-Arrhythmias
Reduce cardiac output —> cerebral hypoperfusion —> syncope
Examples:
- Sick sinus syndrome
- AV blocks
- Paroxysmal SVT/ VT
- Long QT interval
- AF
-Structural
Structural deformity —> impaired ability to increase CO —> cerebral hypoperfusion —> syncope
- Aortic outflow obstruction - e.g. aortic stenosis
- Pericardial tamponade
- Hypertrophic obstructive cardiomyopathy
What are the causes of non-syncopal collapses/ attacks?
Collapse not caused by cerebral hypoperfusion:
Seizures
**Hypoglycaemia **
Intoxication
What are the P’s in the history of a Vasovagal syncope?
Position - upright
Predisposing factors - warm environment, prolonged standing
Precipitating factors - unpleasant stimuli, concurrent illness
Prodrome - pale, clammy, light-headed
Different presentation of syncope vs non-syncopal attacks?
- Risk factors
- Situation
- Onset
- During event
- After event
- Tests
Syncope
- Risk factors
PMHx - heart disease, infection, cardioactiev drugs ( thiazides & anti-arrhythmic’s)
*- Situation *
Predisposing factors - warm environment, prolonged standing
Precipitating factors - unpleasant stimuli, concurrent illness, chest pain, neck movements
*- Onset *
Prodrome - pale, sweaty, nauseous - Vasovagal
Chest pain, palpitations - dysarhythmia/ MI
*- During event *
Weak carotid pulse, low muscles tone, may have some limb jerking
- After event
Few mins for recovery
Brief period of confusion may occur
May be prolonged ( hours) of fatigue
Tongue biting & incontinence possible
- Tests
ECG - abnormal in cardiac causes
BP - orthostatic
Non-syncopal attacks/collapse
-Risk factors
PMHx - stroke, advanced dementia, seizures
Electrolyte disturbance
*- Situation * - N/A
*- Onset *
Aura may occur - gustatory / olfactory
- During event
Muscle tone may be raised with or without movement
Muscle activity and movement can also be seen
Tongue biting - common
Incontinence is comomone
- After event
Slow recovery to full consciousness with prolonged confusion ( minutes to hours)
Ictal period
*- Tests *
EEG - abnormal in seizures
CT - can be abnormal
What is the definition of constipation?
Condition in which there is delayed alimentary tract transit time, leading to:
- the time between bowel evacuations is longer than normal for the patient
- the stool is harder than normal
- the total faecal mass inside the abdomen is increased
What are the three main types of constipation?
1) Hard stool impaction - hard faeces present in the rectum ( often ++)
2) Soft stool impaction - the whole distal bowel is loaded with soft putty like faeces that cannot be evacuated
3) High proximal impaction - may be due to obstructing pathology ( e.g. carcinoma)
What are the causes of constipation? (5)
1) Reduced bowel motility
- drug induced - anti-muscarinics, opiates, iron, antidepressants, antipsychotics, CCBs
- immobility
- illness
- poor diet - low fibre / dehydration
2) Failure to evacuate bowels fully
- Anorectal disease - anal or colorectal cancer, fissures, strictures, herpes, rectal prolapse, levator ani syndrome
- reduced toilet access
- lack of privacy / altered daily routine ( hospital)
3) Neuromuscular - slow transit from decreased peristalsis
- Parkinson’s disease
- diabetic neuropathy pseudo obstruction
- spinal or pelvic nerve injury
4) Mechanical obstruction of the bowel
- carcinoma of the colon
- diverticular disease
-strictures
5) Metabolic / endocrine
- hypercalcaemia
- hypothyroidism
- hypokalaemia
- porphyria
- lead poisoning
What investigations / examinations should be considered in constipation ?
Per rectal examination - to check faecal incontinence and the rectum, the prostate, anal tone and sensation should all be assessed as well as a visual inspection around the anus.
Stool type should be assessed if in the rectum.
Bladder scan - check for retention
Abdominal examination - to check for obstruction / tenderness( only felt if significantly loaded)
If patient is large - may require an AXR to visualise loading if unable to feel on abdominal examination
What medications can be used in constipation? ( 4)
1) Bulking agents
- increase faecal mass - stimulate peristalsis
- Bran powder, Ispaghula husk, Methycellulose, Sterculia
2) Stimulant laxatives
- increase intestinal motility
- Bisacodyl, Senna, Docusate sodium, Glycerol suppositories
3) Stool softeners
- used in hard stool impaction - soften stool to aid evacuation
- Arachis oil (peanuts!)
4) Osmotic laxatives
- retains fluid in the bowel, stimulate peristalsis/ diarrhoea
- Lactulose - produces osmotic diarrhoea
- Macrogol (Movicol)
What medications do you use in soft & hard stool compaction?
What other advice could be given?
Soft stool faecal impaction - microlax enema, stimulant laxatives ( e.g. senna , bisacodyl)
Hard stool faecal impaction - eicosanoid enema ( aka arachis oil - oil-retention enema ) with manual evacuation - ask for peanut allergy as peanut based oil, Bulk forming laxatives (ispaghula husk & sterculia - also acts as a faecal softener)
Use lactulose in both
Non-pharmacological - regular exercise, improving access to the toilet, adequate fibre, adequate water
What is urinary incontinence?
Any involuntary leakage of urine
What are the main types of urinary incontinence?
Overactive bladder
Stress incontinence
Urgency incontinence
Overflow incontinence
Functional incontinence
Mixed incontinence
